Decision is a Sharp Knife

Decision Is A Sharp Knife: The Bougie-Aided Cric

(or, as they say across the pond, Scalpel Bougie Cric)

Thanks Air Care Your #1
Thanks Air Care Your #1

In emergency medicine, EMS, and critical care transport medicine, I think we’d all (at least secretly) agree that there’s absolutely no greater joy than being able to say to ourselves, “That guy (or lady) is still walking the earth because of the care my team and I were able to give him (or her).”  I’m talking about the sort of patient that you bring back from the very brink of death with knowledge and skill borne of hard work and practice.

A few times in your career, it’s likely that fate will cross your path with that of a patient with CICO—Can’t Intubate, Can’t Oxygenate—and you just may have the opportunity to experience that sort of joy.  Granted, the pathophysiology leading to the CICO situation will be formidable and the odds will be against you.  If that patient is 12 or older, in such a situation, you’re going to need to be ready to perform a surgical cricothyrotomy without hesitation.  History teaches that most of us will hesitate, and if we do, the opportunity will likely be lost.  Airway master Dr. Rich Levitan teaches that to avoid such potentially catastrophic hesitation, to decide to cut without delay, we need three things: anatomic insight, technical skill, and mental armor.

To gain these three critical elements, there are several things we’re going to need to recognize:

  • A “failed airway” is not a failure.  Some will happen to all of us.  When CICO—refractory to perfect BMV technique and/or supraglottic airway-- happens, declare it.  Share your mental model with the team.  CICO—say it aloud.
  • This procedure will be blind.  Don’t kid yourself otherwise.
  • The toughest part of this procedure, other than making the initial decision to cut, is actually passing the ETT or trach tube through the hole you’ve made.  If you don’t do it correctly, losing the hole entirely, or creating a false passage, is all too easy.  Therefore, once you’ve cut to air-- once the tip of your scalpel is in the lumen of the trachea—refuse to relinquish control of that tracheal lumen.  Keep something in that lumen at all times until you’re looking at nice square capnographic boxes confirming you’ve succeeded.  And, to do this procedure in 2014 without a bougie or a bougie-like introducer (like you’ll find on Dr. Levitan’s Cric-Key device) to help you avoid false passage, in my opinion, takes hubris that your patient cannot afford for you to have.
  • The vocal cords live behind the thyroid cartilage. The entire procedure is done below them.
  • Ergonomics are huge.  If you’re right-handed, stand by the patient’s right. If you’re left-handed, stand by the patient’s left.  Your non-dominant hand perfectly controls the thyroid cartilage, guarding against movement, throughout the procedure.Your amped-up dominant hand rests on the patient’s sternum as you cut, enabling you to maintain fine motor control.
  • None of us will ever get to physically practice this procedure enough, no matter how much we supplement our clinical practice with skills training in the sim lab or the cadaver lab.  So we have to practice it mentally.  A very wise man (Scott Weingart, Cliff Reid, or Minh Le Cong… I honestly can’t recall) once said: “You have, between your ears, the world’s most advanced high-fidelity medical simulator.”  I have a routine during my commute to each and every shift I work.  It involves Rush, Metallica, or Dream Theater, and it involves me visualizing every step, every detail, of successfully performing a cric.  I’ve physically practiced the procedure maybe 100 times in my career.  Mentally, I’ve done it at least 2000 times.

To help get the key steps of the procedure down, watch the procedural slide set below...

To get the best sense of what it actually like to perform the procedure, watch the first-person video of the procedure below...


  4. Braude D, Webb H, Stafford J, et al. The bougie-aided cricothyrotomy. Air Med J 2009 Jul-Aug; 28(4): 191-4. Link to abstract
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